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HomeMy WebLinkAboutApp-Permit-ComplianceNo, I AtC -22 ' FEE- 6q),- EE6q),- l i j � �COMM NAVE -A ETII OF MASSACHUSETTS Board r f fYraltla, APPLICATION OIC. DISP, SA,L SYSTEM GONS TRI CTION P-ERM1 1T Application fora PCITfiit to Construct( ) Repair( Upgrade( ) Abandon() © Complete System ❑ Individual Components Location Owncf's Name ���"� 0'-U. map/Parcel# L19 Address l.ot# Teleph'ouc# Installer's Name �� 1 � ! C Designer's Name --Off Aciclress ,�,�) x--2 -7 Address Telephone#4� Telephone# - Type of Building /!u Dwelling - No. of Bedroorns Other - Type of Building _ Other Fixtures Design Flow (min. requl•ed) flan: Date Title. Description orsoil(s) gpd Calculated design flow Number of sheets Soil Evaluator Form No. Name of Soil Evaluator DESCRIPTIOiN OF REPAIRS OR ALTERATIONS S Lot Size No. orpersoris sq. ft. Garbage grinder ( } Showers ( ), Cafeteria ( } Design flow provided gpd Revision Date Date of Evaluation ��4am The undet:sigi]ed ,tes to install the above descri it Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further afire - • o not 1, a the syst in op ation int' a C •tificate of Co pliance fps been issued by the Board of Health Signed Date -- �, / JUL 1 4 2022 Inspection's , V No. E� CCL ., o ICI®MMONWEA11I4 OF MASSAICIIUSI.-TTS 4 d I3ncr -d of Recrllla, ,s , fblfL c�l " � C) r ICr_P.TIFICATE 6T {COMPLIANCE ca llz� lk.' Description of Work: © Individual Component(s) © Complete System The undersigned hereby certify that,the Sewage Disposal System; Constructed ( ), Repaired), Upgraded ( ), Abandoned ( ) at 4X 5 -- has cen --has%een installed in accordance with the provisions of 310 CiVIR 15.00 (Title 5) and the approved design plans/as-built plans rel, t01 application No. , Q � dated '-� `.1. Approved Design Flow (gpd) Installer Designer: `° `" Inspector: ,�,.,...) & i Date: i"- i s 1 The issuance of this permit shall not be construed as a guarantee that the system will function as designed. COMY[IONWEALTII Of MASS. {CI USETTS Board (f F1ealth,'s-'." R AIA. DISPOSAL SYSTEM�CONS RUCTION PERMIT FEE w Permission is hereby granted to; Constrytct( ) Repair(t Upgypde( ) Abandon( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No.dated � t1 ty A� Provided: Construction shall be completed within lrlee-gems of the date of this permit. All Iocal conditions must be met. Form 1255 Rev. 5196 A.M.SulklnCo, Chsdestun,MA Date �' ��'" Board of Health